What Is the Legal `Standard of Medical Care' When There Is No Standard Medical Care? A Survey of the Use of Home Apnea Monitoring by Neonatology Fellowship Training Programs in the United States

摘要

In treating a patient, a doctor is obliged to use the skill and care that is ordinarily used by reasonably well-qualified doctors in similar cases. In addition, the only way in which a juror may decide whether the defendant used the skill and care which the law required of him or her is from evidence presented by doctors called as expert witnesses (cf Illinois Pattern Jury Instructions ). However, what should be done if expert opinions differ concerning the care that is "ordinarily used"? Home apnea monitoring (HAM) is prescribed at times for graduates of neonatal intensive care units despite the fact that indications for its use are not well established and efficacy is completely unknown. The authors attempted to determine standards for HAM as it is currently practiced in neonatology training programs. The primary teaching hospital for each of the 99 neonatology training programs in the United States was identified. Both the medical director (MD) and a neonatal intensive care unit nurse manager (RN) were asked about the use of HAM in their own nursery for four clinical vignettes. Each vignette depicted a 1000-g birth weight infant, currently 7 weeks old and ready for discharge. In three vignettes, the infant had demonstrated no apnea, mild apnea (resolved by 2 weeks of age), or moderate apnea (requiring theophylline therapy at discharge) during the hospital course. In the fourth vignette, the infant had no apnea but was to be discharged home with supplemental oxygen. For 67 of 99 training programs, paired responses of RN managers and MD directors were obtained. For infants with no apnea or mild apnea, approximately 85% of RN/MD pairs agreed that HAM would not be used at their institution, 2% would use HAM, and 12% responded that they might use HAM depending on individual circumstances. In contrast, for the premature infant with moderate apnea, there was much less agreement. Sixteen percent of RN/MD pairs responded that HAM would not be used, 39% would use HAM, and 19% might. Remarkably, for this vignette 25% of the RN/MD responses disagreed on the practice of HAM at their own center. Similarly, for the infant with home oxygen, 15% of RN/MD responses agreed that HAM would not be used, 49% answered that HAM would be used, 10% were uncertain, and 25% disagreed on the use of HAM at their own center. It is concluded that (1) for premature infants with no or mild apnea, HAM is currently prescribed by a minority of fellowship-associated neonatology programs, and (2) no obvious consensus exists for HAM in the context of moderate apnea or home oxygen therapy. For many infants, there is no "standard care" for HAM in the neonatology community at this time. "Expert" opinions of the legal "standard of care" for HAM should reflect this fact.